Creating A Healthy Environment

The Impact of the Built Environment on Public Health
“In its broadest sense, environmental health comprises those aspects of human health, disease, and injury that are determined or influenced by factors in the environment. This includes not only the study of the direct pathological effects of various chemical, physical, and biological agents, but also the effects on health of the broad physical and social environment, which includes housing, urban development, land-use and transportation, industry, and agriculture.” —Healthy People 2010, U.S. Department of Health and Human Services 1

Richard J. Jackson, MD, MPH Chris Kochtitzky, MSP
Centers for Disease Control and Prevention











Sprawl Watch Clearinghouse would like to thank Jonathan Dushoff, of Princeton University; Peter Engelke, of the City and Regional Planning Program, College of Architecture, Georgia Institute of Technology; Karen Roof, of the National Association of County and City Health Officials; Marla Hollander, of the Robert Wood Johnson Foundation; Rich Killingsworth, of the CDC’s National Center for Chronic Disease Prevention and Health Promotion; Pat Meehan, of the CDC’s National Center for Environmental Health; Lee Epstein, of the Chesapeake Bay Foundation; Chuck Connerly, of the Florida State University Department of Urban and Regional Planning; Bob Deyle, of the Florida State University Department of Urban and Regional Planning; Rebecca Miles, of the Florida State University Department of Urban and Regional Planning; Rich Shieber, of the CDC’s National Center for Injury Prevention and Control; Bruce Stiftel, of the Florida State University Department of Urban and Regional Planning; Dorothy Sussman, of the CDC’s National Center for Environmental Health; Patti Seikus, of the CDC’s National Center for Environmental Health; Don Lollar, of the CDC’s National Center for Birth Defects and Developmental Disabilities; Maisha Kambon, CDC’s National Center for Environmental Health; Robert Weissman, of Essential Information and Betsy Garside, of the American Farmland Trust for their help in editing this report and the Educational Foundation of America whose support made this report possible.

About the Authors
Dr. Richard Joseph Jackson, MD, MPH Dr. Richard Jackson is the Director of the National Center for Environmental Health of the Centers for Disease Control and Prevention. During his tenure at NCEH, he has worked to increase support for stronger environmental health protection efforts throughout federal agencies, to engage CDC and local and state health departments in the genetics “revolution,” and to increase efforts to improve the nutritional status of people in developing countries. In addition, Dr. Jackson is collaborating with groups and individuals from many disciplines; planners, architects, engineers, academicians, and policy makers’ to explore the implications of urban sprawl on the nation’s environmental health. Jackson received his baccalaureate degree from St. Peter’s College in Jersey City; a Master of Medical Sciences degree from Rutgers Medical School in New Brunswick; his M.D. from the University of California, San Francisco; and his M.P.H. in epidemiology from the University of California at Berkeley. Chris Kochtitzky, MSP Chris Kochtitzky is the Associate Director for Policy and Planning in the Centers for Disease Control and Preventions National Center for Environmental Health, Division of Emergency and Environmental Health Services. Mr. Kochtitzky was hired as senior legislative analyst at the Centers for Disease Control and Prevention’s (CDC’s) National Center for Environmental Health (NCEH). NCEH is one of CDC’s key centers with responsibilities involving the impact that the environment (both natural and manmade) has on human health. In his years at NCEH, Mr. Kochtitzky has also served as Acting Deputy Associate Director of the Office of Planning, Evaluation, and Legislation, which is responsible for strategic planning and policy analysis within the center. Kochtitzky received a BA in political science in 1989 from Millsaps College and an MS in planning, with a concentration in environmental and natural resources planning, from Florida State University in 1992.

About Sprawl Watch Clearinghouse
The Sprawl Watch Clearinghouse mission is to make the tools, techniques, and strategies developed to manage growth, accessible to citizens, grassroots organizations, environmentalists, public officials, planners, architects, the media and business leaders. At the Clearinghouse we identify, collect, compile, and disseminate information on the best land use practices, for those listed above. Sprawl Watch Clearinghouse is a nonprofit organization based in Washington, DC Allison Smiley, Executive Director This report and many other sources of information on sprawl and smart growth are available on the World Wide Web at
Sprawl Watch Clearinghouse • 1400 16th St., NW • Suite 225 • Washington, DC 20036 • 202-332-7000 •

These diseases-heart disease. and overall improved physical and mental health. It is now accepted that. In addition. especially asthma.S. not only in this country but across the globe.Preface Here at the start of the 21st century our understanding of which factors promote health and which damage health has grown considerably. Less driving. The most effective weight loss strategies are those that include an increase in overall physical activity. Land-use decisions are just as much public health decisions as are decisions about food preparation. Respiratory disease. It means thinking about what constitutes safe and affordable housing. and diabetes is a major risk factor for amputations. Bad air makes lung diseases. providing green space for people to enjoy where they live and work. diabetes.6%. so does the physical and mental health of the people who live in them. in addition to direct hazards from infectious diseases and environmental toxins.5%. Jackson. especially asthma. and rethinking how we travel from one place to another. As we begin to include consideration of these factors into our health-related decision-making. that can result when people live and work in accessible. There is a connection. so that we are all “at the table” when environmental decisions are made. asthma admissions to ERs and hospitals also decreased by 41. well-designed. thoughtful structures and landscapes. between the fact that the urban sprawl we live with daily makes no room for sidewalks or bike paths and the fact that we are an overweight. jog. and heart disease. blindness. It is dishonest to tell our citizens to walk. The diseases of the 21st century will be “chronic” diseases. we must additionally guard against using too narrow a definition of the environment.are diseases that can be moderated by how we design and build our human environment. is increasing yearly in the U. are the implications for children with asthma of building yet another expressway? We must also question whether a fatality involving a pedestrian isn’t actually the result of poor urban planning. and depression. What. population. Every person has a stake in environmental public health. planners and transportation officials. in earnest. human behaviors play a critical role in determining human health. Obesity can increase the risk of (adult-onset) type 2 diabetes by as much as 34 fold. nurses. In a recent type 2 diabetes trial. asthma. heart disease-ridden society. driving over impervious highways that generate massive tree-removal. those that steal vitality and productivity. worse. thoughtless land use. When the Atlanta Olympic Games in 1996 brought about a reduction in auto use by 22. for example. kidney failure. well designed landscape and residential density will improve air quality more than will additional roadways. including less stress. and as environments deteriorate. physical activity is as effective as the most commonly prescribed medications. or inferior urban design rather than “simply” a motor vehicle crash. safe. weight loss and physical activity were more effective in controlling the disease than medication. and we must begin. for treatment of relatively mild cases of anxiety and depression. In order to address these critical health problems we must seize opportunities to form coalitions between doctors. lower blood pressure. We must be alert to the health benefits. to frame those decisions in light of the well being of children. for example. The more hours in automobiles. MD. or bicycle when there is no safe or welcoming place to pursue these “life-saving” activities. MPH Director. and public health professionals and others such as architects. builders. clearly degrade air quality. safe neighborhoods. better public transport. obesity. and consume time and money. Such decisions include whether to install sidewalks in the next subdivision. CDC’s National Center for Environmental Health . We must measure the impact of environmental decisions on real people. Richard J.

it is also becoming clear that it is an unhealthy experience. and we ignore them at our peril. as potential health ○ W hen people consider factors adversely affecting their health. transportation choices. We have always known that a 2-hour commute to work each day on America’s freeways is not a pleasant experience. people suffer the consequences. when these factors are ignored or poorly executed. ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ to make the connection between these all-too-common facets of everyday life and how ○ ○ patterns. or architectural or urban-design decisions. the impact of these factors grows clearer. However. Rarely do they ○ ○ ○ ○ ○ ○ ○ ○ 4 S PUBLIC HEALTH/LAND-USE MONOGRAPH Photo: USDA ○ ○ ○ ○ ○ ○ . As America increasingly becomes a nation that permits and even encourages thoughtless development and unmanaged growth. land-use ○ ○ ○ ○ on influences. the ecosystems in our communities collapse.Introduction hazards. Yet we often fail unhealthy we are. such as poor diet or the need for more exercise. such as housing characteristics. We see evidence every day that Americans exercise less often and suffer higher levels of stress than they did in the past. they generally focus consider less traditional factors.

Snow’s that resulted in improved sanitation. the U.. and infrastructure) in terms of whether it promotes or discourages physical activity. As a result of this discovery and Dr.S. we focus mainly on the following: S The relation of land-use decisions to air quality and respiratory health. cleaner air and water. We believe that applying public health criteria to land-use and urban design decisions could ○ substantially improve the health and quality of life of the American people. in this monograph. S The impact of urban design on the number of pedestrian injuries and deaths. cited public health protection as one of the basic responsibilities of local governments. In recent years. but also work to prevent it. sanitation. mental. particularly among children. Much of the improvement in disease death rates in the last century can be attributed to basic environmental public health actions such as Dr. and S The ways that various land-use decisions affect community water quality. and social well-being. with a final section that describes some steps that both the planning community and the public health community can take to ensure that public health concerns figure prominently in decisions made about the built environment. Supreme Court. John Snow was credited with taking bold action when he suspected that contaminated water from a public pump on Broad Street was causing a deadly cholera outbreak in London. and the incidence of disease outbreaks.”4 Environmental public health initiatives have historically been among the most effective approaches for assuring healthy living conditions. open spaces.”3 The National Academy of Science’s Institute of Medicine has asserted that the public health system should “fulfill society’s interest in assuring conditions in which people can be healthy. The World Health Organization (WHO) has defined health as “a state of complete physical. injury prevention. A brief summary of other health impacts of urban sprawl is also included. Dr. public health organizations have emphasized that public health agencies and programs must not only control disease. in Village of Euclid vs. discuss how they affect our health. In 1854. streets. not just the absence of disease or infirmity. As far back as 1926.Land-use planning and zoning have their roots in a desire to protect the public’s health. Therefore. ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ PUBLIC HEALTH/LAND-USE MONOGRAPH S 5 .2 In this monograph. and protection of citizens from dangers posed by industrial pollution in their communities. and offer some suggestions on how public health professionals can collaborate with their colleagues in land-use planning and urban design to help ensure the health and quality of life of the people in their communities. S The built environment (including all manmade physical components of human settlements such as buildings. thus giving them a legal mandate to restrict or control landuse decisions in a community. Ambler Realty Co. S The choices communities make about the built environment that improve mobility and the quality of life for their elderly and disabled residents. Snow’s actions to remove the handle on the pump. we address some of these land-use decisions. the cholera outbreak ended.

prawl — uncontrolled. shop. S Approximately 36.12 Also presented at the conference were results from a recent study of the health effects of air pollutants from traffic in Austria. This study. found that air pollution caused 6 percent of total mortality in the three countries. in Orlando 62 percent. When researchers analyzed the data from the study they found that automobile-related pollution was responsible for more deaths than traffic accidents. For instance.000 deaths per year. in Atlanta 44 percent. low-density. 11 Research presented on the impact of automobiles and the transportation sector on human health at the Third Ministerial Conference on Environment and Health held in London in 1999 indicated the following: S Motor vehicle traffic is the main source of ground-level urban concentrations of air pollutants with recognized hazardous properties. more than 40. and single-use community growth — depends on individual motor vehicles to flourish. in 1997. NOx and VOCs contribute to ground-level ozone pollution.6 This dependence on the automobile has only accelerated in recent years.12 Data from studies conducted in the United States strongly suggest significant links between ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ .8 This increase in driving time results in an increase in air pollution and in the incidence of respiratory diseases. this traffic contributes practically all CO. France and Switzerland and their related costs. About half of all mortality caused by air pollution was attributed to motorized traffic. and play.8 billion in U. dollars).10.000 to 129. In Northern Europe. The economic burden of the health impact of automobile pollution was estimated at more than EUR 27 billion (approximately $23. on-road 6 S PUBLIC HEALTH/LAND-USE MONOGRAPH S ○ ○ ○ ○ ○ ○ ○ ○ ○ Land-use and Its Effects on Air Quality and Respiratory Health vehicles accounted for about 58 percent of carbon monoxide (CO) emissions in the United States.9 According to a recent report completed by the Congressional Research Service. nearly 30 percent of nitrogen oxides (NOx). roughly 27 percent of volatile organic compounds (VOCs). while the proportion of workers commuting within their counties of residence declined. As people move farther and farther from cities. because even though individual cars pollute less. and in Kansas City 81 percent.000 adult deaths a year can be attributed to long-term exposure to air pollution generated by traffic in European cities. Despite tremendous progress in reducing U.7 Residents of cities that have grown more over the last decade have also experienced a greater increase in the average time spent traveling in a car than residents of cities where growth has remained stable. which is known as smog. 75 percent of NOx.S. From 1992 through 1996. the number of cars and trucks and the number of miles people drive increases. This corresponds to about twice the number of deaths due to traffic accidents in these countries. according to the Sierra Club. From 1960 through 1990. the average American driver spends 443 hours each year behind the wheel — the equivalent of 55 nine-hour days or 11 work weeks. air pollution since the passage of the Clean Air Act almost 30 years ago.5 This trend contributed to an increase in the number of vehicle miles traveled in passenger cars — an increase of more than 250 percent (915 billion miles) from 1960 through 1997. the percentage of workers with jobs outside their counties of residence increased by 200 percent. cars and trucks are still a major source of pollution. they inevitably will travel longer distances to work. the increase in the number of annual person-hours of delay spent in an automobile in Los Angeles was 9 percent.S. and about 40 percent of the particulate matter (PM10) concentrations. poorly planned. and about 9 percent of particulate matter (PM). using comparable methods.

in the summer of 1997.000 visits to emergency rooms for treatment of asthma attacks. For example.9 percent and peak weekday morning traffic counts dropped 22.000 asthma-related hospitalizations. some evidence suggests that exposure to ozone can enhance a person’s responsiveness to other inhaled allergens. more than 25 percent of which comes from auto emissions.5 million. asthma attacks that were directly attributed to excessive ozone pollution numbered approximately 86. Environmental Protection Agency’s (EPA) limits for ozone.15 Results that support the Atlanta findings were found in a 1999 study of adverse health effects associated with ozone in the eastern United States. smog pollution was responsible for more than 6 million asthma attacks. these problems will most likely only worsen.3 million17 to 5. and particulate matter are respiratory irritants and can exacerbate asthma.000 in Richmond.13 As many as 25 percent of children in America live in areas that regularly exceed the U. such as ozone. ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ PUBLIC HEALTH/LAND-USE MONOGRAPH S 7 .S. Air pollution may also act synergistically with other environmental factors to worsen asthma. 159. from 2.6 percent. conducted by ABT Associates. 27.air pollution and negative health outcomes such as asthma. The President’s Task Force on Environmental Health Risks and Safety Risks to Children reports that: “Many common air pollutants. sulfur dioxide. As the American population drives longer distances. and 130.16 Children with asthma are believed to be particularly sensitive to air pollution. and 53. at the same time the number of asthma emergency medical events dropped by 41. D. will reduce their dependence on medication for asthma management. Nonasthma medical events did not drop during the same time period. showed that the peak daily ozone concentrations decreased 27. it seems imperative that new transportation options be developed and implemented in order to help alleviate the public health problems related to worsening air quality in the United States.000 in Baltimore.13 Asthma rates among children in the United States more than doubled from 1980 through 1995.C.”13 For instance. and will improve their overall lung function.14 Results of a study conducted by the Centers for Disease Control and Prevention (CDC) during the 1996 Olympic Games in Atlanta.5 percent. Whether long term exposure to these pollutants can actually contribute to the development of asthma is not yet known. found that during a single ozone season. at which time vehicular traffic was kept at artificially low levels by city authorities.13 The significant contribution of automobile use to the overall air pollution problem seems clear.000 in Washington. This study.18 Reducing children’s exposure to environmental pollutants such as ozone will reduce the frequency and severity of their asthma attacks. Therefore.

S Prevention or delay of the onset of high blood pressure and actual lowering of blood pressure among people with hypertension. S Decreased risk for colon cancer. CDC reports that higher levels of perceived neighborhood safety are associated with higher levels of physical activity. schools.20 Research by CDC and others 21. In 1977.24 Results of a study in South Carolina showed that students are four times more likely to walk to schools built before 1983 than to those built ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ . enjoyable scenery.S. S Relief of the symptoms of depression and anxiety and improvement of mood.19 The built environment presents both opportunities for and barriers to participation in physical activity. and S Apparent improvement in health-related quality of life by enhancing psychological well-being and by improving physical functioning among people with poor health. but one of the strongest theories is the significant decline in activity levels among Americans today compared with levels from 50 or 100 years ago. Millions of Americans drive to and from work and use a car to run almost every errand. One study examined environmental variables. such as the presence or absence of sidewalks. children aged 5 to 15 years walked or biked for 15. street lights.23 According to the U. and high levels of crime. people are more likely to use parks. whereas the greatest perceived barrier was the lack of a safe place to exercise.The Built Environment and Physical Activity eople who participate in regular physical activity reap substantial health benefits. by 1995. thereby influencing whether or not we exercise. with the differences being greatest among racial or ethnic minorities and people older than 65 years of age. and places of employment and residence increases. children made only 9. Overall.19 changes in our lifestyles and communities have played the greatest role in the decline of activity levels among Americans. heavy traffic. Many theories have attempted to explain the radical changes in the health status of American society. S Weight loss and redistribution of body fat. paths. frequent observations of others exercising. Conversely.8 percent of all their trips. 22 has also indicated that two of the main reasons given as reasons for not exercising are lack of structures or facilities (such as sidewalks 8 S PUBLIC HEALTH/LAND-USE MONOGRAPH ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ P ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ and parks) and fears about safety. hills. S Lowered risk for noninsulin-dependent diabetes.9 percent of their trips by foot or bicycle — a 37 percent decline.20 one of the more important determinants of physical activity is a person’s immediate environment (one’s neighborhood).21 Thus. increase in muscle mass. According to a recent survey about research studies. and bikeways when they are easy to get to and are safe and well maintained. Surgeon General’s Report on Physical Activity in America. Positive environmental determinants of physical activity included enjoyable scenery (presence associated with more activity). According to the Surgeon General the most significant are as follows: S Lower mortality rates for both older and younger adults. S Lower risk for heart disease and stroke. unattended dogs. Even moderate increases in activity are helpful. people tend to get less exercise as outlying suburbs are further developed and the distances between malls.

the design of most new residential areas reflects the supposition that people will drive to most destinations.25 This would seem to point to some basic change in the “walkability” of newer schools.29 we can conservatively attribute an overall health care burden of more than $100 billion to obesity and low levels of physical activity in the United States each year. In addition.29 Adding to that figure the estimated direct health care costs of physical inactivity ($37 billion). Figure 1 ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ PUBLIC HEALTH/LAND-USE MONOGRAPH S 9 . From 1976 through 1994. many different types of urban design encourage sedentary living habits. the prevalence of U. Sedentary living habits also contribute to poor health outcomes because they are a significant factor in the incidence of overweight and obesity. adults who were overweight or obese rose from 47 percent to 56 percent. Work.27 Some researchers have estimated that as many as 300. possibly because these schools aren’t as geographically close to the students they serve or because the school’s property and its environs were designed to meet the needs of automobiles rather than the needs of pedestrians and bicyclists. was the fact that the prevalence of overweight children and adolescents almost doubled during this same period. While older cities and towns were planned and built based on the practical idea that stores and services should be within walking distance of residences. home. Major health care costs are also associated with the lack of physical activity and concomitant rises in obesity rates. parking lots are built as close as possible to final destinations in order to increase convenience and safety for motorists. however. and by 1999 had risen to 61 percent.S.26 More disturbing. For example. the direct health care costs of obesity were estimated at $70 billion.more recently.28 Figures 1-3 show the alarming increase in obesity prevalence among adults in the United States during a single decade. school. and shopping are often separated by distances that not only discourage walking but may even necessitate the use of a car in order to reach any destination safely.000 premature chronic disease deaths each year are due to obesity. In 1995.

Figure 3 Figure 2 10 S PUBLIC HEALTH/LAND-USE MONOGRAPH ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ .

Although Americans make fewer than 6 percent of their trips on foot. parks. Restricting curb parking at specific crossing points may be an effective approach to reducing children’s injuries in this arena.31 ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ A Several regulatory and design strategies can be applied to make communities safer for both child and adult pedestrians and bicyclists. These strategies include (1) setting and enforcing lower speed limits in residential areas.696 people — were pedestrians. almost 60 percent occurred in places where no crosswalk was available. (5) providing crossing guards and bike paths in areas where most pedestrians are children. The risk for injury to children living in neighborhoods with the highest traffic volumes was 13 times that of children living in the least-busy areas. of the pedestrian deaths for which information is recorded. ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ PUBLIC HEALTH/LAND-USE MONOGRAPH S 11 Photo: Hugh Morris ○ ○ ○ ○ ○ ○ ○ ○ ○ . even though only 13 percent of the population is elderly 30. (4) providing sidewalks and pedestrian walkways. Particularly strong associations were found between the risk for pedestrian injuries and high traffic volume. while 22 percent were older than 65 years of age. near schools. southern and western communities where transportation systems are more focused on the automobile at the expense of other transportation options. and playgrounds) and (6) providing overpasses.30 The report concluded that the most dangerous metropolitan areas for walkers were newer.500 of these victims were children. 13 percent of all traffic fatalities occur among pedestrians. away from motorists. underpasses or tunnels for pedestrians and bicyclists to bypass particularly dangerous roads and intersections. Approximately 1.Urban Design and Pedestrian and Bicyclist Safety nother important issue is the impact of urban design on a number of injuries involving pedestrians and bicyclists.g. Inherent in each strategy is a refocusing of design goals toward pedestrians and. 13 percent of all traffic fatalities — 10. A study conducted in New Zealand asserted that there are several potentially modifiable environmental risk factors for injury to child pedestrians. to a degree. (e. such as traffic circles or speed bumps. According to a recent report by the Surface Transportation Policy Project.. (2) protecting pedestrians in crosswalks by using traffic signals. (3) instituting and enforcing “trafficcalming” measures. in 1997 and 1998. sprawling.

people with disabilities often find that they cannot move easily from place to place and that they have trouble gaining access to medical and other basic health care and social services. they are critical health issues. for example. motorized scooters. A study in Houston. and communities which by their presence.). Fewer than 10 percent of the disabled and elderly use public transportation in Houston. and engineers must keep in mind the needs of all community members. these issues are not simply about convenience or even quality of life. if asked. In addition. Usability and aesthetics are mutually compatible. would probably claim as a right. mass transit is nonexistent. ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ . Such circumstances can therefore make life very difficult for anyone who cannot drive or does not have easy access to an automobile. and distances to commercial facilities make pedestrian access impossible. etc. found that three out of five disabled and elderly people do not have sidewalks between their residences and the nearest bus stop. Although close to 50 percent of the elderly and disabled live within two blocks of a bus stop. facilities. with the pronounced hardships experienced by the elderly and disabled. the lack of sidewalks. something as simple as the lack of a sidewalk or curb cut keeps people with disabilities from getting any physical activity at all. Without access in the community.33 Efforts to address these barriers through “universal design” have begun to show significant success. environments and communications should be designed to consider the needs of the widest possible array of users. planners.33 12 S PUBLIC HEALTH/LAND-USE MONOGRAPH For elderly citizens and people with disabilities.”32 These attributes can include the absence of ramps for wheelchairs.33 An even greater percentage of these households lack depressed curbs in their neighborhoods (71 percent) and bus shelters by the nearest bus stops (76 percent). Environmental barriers are defined as the “physical attributes of buildings. or design present unsafe conditions and/or deter access and free mobility for the physically handicapped. absence. Universal design is a way of thinking about design that is based on the following premises: varying ability is not a special condition of the few but a common characteristic of being human. Texas. Thus. rather. It is easy to see that if citizens in an urban setting such as Houston have encountered environmental barriers to mobility and accessibility. walkers. Often.34 As land-use and urban-design decisions are made. However. these groups cannot adequately participate in physical activity. and lack access to mass transit routes or other public services. lack of depressed curbs (periodic breaks in curbs that act as ramps). curb cuts. narrow doorways that cannot accommodate various assistive devices (such as wheelchairs.Environmental Barriers for the Elderly and People with a Disability F ree and easy movement through public areas in the communities where we live is something most people take for granted and. In suburban parts of these cities and certainly in more rural areas of the country. lack of physical access in a community becomes a factor leading to illness and even death. or get to or use health care facilities. and bus shelters actually makes use of the transportation system by these people impossible. and we change physically and intellectually throughout our life. The concept of universal design maintains that — “…all products. architects. People with disabilities are even more vulnerable to “environmental barriers” than children or the elderly. establish a community of support. fear of crime prevents close to two-thirds of the elderly and disabled from walking to the bus stop at night. Residents of the urban areas of most major cities in the United States such as Houston have access to some type of mass transit and can also find residential housing that permits some amount of pedestrian access to needed shopping and service facilities. people living in suburban or rural settings may face even greater challenges.

approximately 40. It flows across compacted earth and impervious man-made surfaces (e..38 ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ PUBLIC HEALTH/LAND-USE MONOGRAPH S 13 Photo: USDA ○ ○ ○ ○ ○ ○ . while outbreaks due to groundwater contamination were most often delayed by a month or two. In contrast.37 An additional threat to water quality posed by sprawling uncontrolled growth is the overuse of septic systems in low-density suburban and rural residential development that results in groundwater contamination. Since 1990. in 1998. Under natural conditions.36 According to research published in 2001 by Johns Hopkins University. It is estimated that OSTDS discharge 450 million gallons per day of partially treated. more than 50 percent of waterborne disease outbreaks between 1948 and ○ ○ ○ ○ ○ ○ ○ ○ ○ U 1994 were preceded by extreme rainfall events. In urbanized areas. More than 1.000 new systems have been installed each year.8 million systems were estimated to be in use statewide. according to the 1990 United States Census. This disruption of the natural hydrologic cycle causes stormwater runoff to reach streams and rivers more quickly than these water bodies can absorb it and also before it has had an adequate chance for filtration of pollutants through the ground (the flush of auto contaminants from malls and other large parking areas that runs into surface water bodies during the initial period of a heavy rainfall contributes significantly to the non-point source loading of pollutants entering streams). For instance. approximately 26 percent of Florida’s population was served by onsite sewage treatment and disposal systems (OSTDS). These findings can. asphalt. while the amount of land developed in that same period rose by 87 percent. nondisinfected wastewater.651 OSTDS abandonment permits where establishments were being connected to a central sewer system. rainfall is either intercepted by vegetation or percolates slowly through the soil to receiving waters. thereby rendering the land incapable of absorbing and filtering the amount of water that falls during these extreme weather events. central Puget Sound experienced a 38 percent increase in population. rooftops often covered with oil and other pollutants) and is channeled into storm drains.g. in some part. Outbreaks due to surface water contamination were most strongly and most immediately related. be attributed to the increase in impervious surfaces in areas of population concentration. The volume of stormwater that washes off oneacre parking lots is about 16 times greater than that of a comparable size meadow. By comparison. the Department of Health only issued 3. This large-scale alteration of the natural landscape had profound effects on water resources and quality. Between 1970 and 1990.The Impact of Uncontrolled Growth on Water Quality ncontrolled growth and the loss of greenspace that often accompanies it can drastically affect both surface and groundwater quality. concrete. impervious surfaces have the highest runoff rates.35 Undisturbed forested lands generally have the highest capacity to absorb water and subsequently the lowest rates of stormwater runoff. rainfall that once filtered slowly downhill becomes surface runoff.

42 S Residential development next to farmland can pose unique health and quality-of-life concerns as well. L blowing dust. which are natural floodabsorbing sponges. defined by EPA as abandoned. Heat islands are created when natural vegetation is replaced by heat-absorbing surfaces such as building roofs and walls.43 S As sprawl-type development pulls people and resources away from central cities. when these sites are redeveloped. called “brownfields. This phenomenon can raise air temperature in a city by between 2-8°F. and streets. In the last 8 years. such as excess noise. Sprawl and overdevelopment is closely correlated with a range of harmful public impacts: S In a study of conflict and violence in and around public housing in Chicago. In this “zone of conflict. Some of these properties. floods in the United States killed more than 850 people and caused at least $89 billion in property damage. and in some cases EPA may enter into agreements with prospective purchasers of property. and reported using less violent ways of dealing with domestic conflicts. be the only type of property a school district feels it can afford. researchers found that the residents of buildings with surrounding greenspace had a stronger sense of community.Other Potential Health Effects of Land-use Decisions and-use decisions and the built environment affect the way humans act and interact. Brownfields. rather than residential property standards which are more stringent.46 ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 14 S PUBLIC HEALTH/LAND-USE MONOGRAPH ○ Washington Post ○ ○ ○ ○ ○ ○ ○ ○ . and accelerate the formation of smog. increase the health risks associated with heat-related illnesses and deaths. providing a covenant not to sue for existing contamination. particularly with their partners. they are only cleaned up to standards set for commercial or industrial property. School districts pressed to save money are often enticed by donations of unknowingly contaminated property or seek out the cheapest land they can find. The land is cheap. in some instances.” which might extend one-third of a mile from residential development. had better relationships with their neighbors. parking lots.40. those left behind can experience many negative consequences.45 Some groups feel that the supposed community benefit of cleaning up and reusing an abandoned site is outweighed by the risks posed if. 41 S Sprawl increases the risk of flooding. Much of this flooding occurred in places where weak zoning laws allowed developers to drain wetlands and build on floodplains.39 S Urban heat islands increase the demand for cooling energy.” are touted as the answer to all of the problems facing financially strapped school districts. and pesticide overspray potentially can have negative health effects on the occupants of the residential development. or underused industrial and commercial facilities where expansion or redevelopment is complicated by real or perceived environmental contamination. idled. the spillover effects of agriculture.44 can. Development pressures lead to the destruction of wetlands. with myriad impacts on public health.

Today. Their efforts led to an investigation that revealed widespread campus contamination. and the reduction in impervious surfaces. Just as traffic studies are completed to ensure that road capacity can support new growth. In 1990. included at least four that are significantly linked to some of the land-use and urban design issues. and (4) reducing the toll of violence in society. so too should the public health community conduct research to determine the air quality impacts that increasing numbers of automobiles in use in a community have on its air quality. CDC Director Jeffrey Koplan. and architects must begin to see that they have a critical role in public health. and bike paths. MD.46 Planners. sidewalks. engineers. In a recently published list of the 10 most important public health challenges for the new century.” Urban planners. We must integrate our concepts of “public health issues” with “urban planning issues. and Public Health Professionals Can Make a Difference The challenge facing those with responsibility for assuring the health and quality of life of Americans is clear. such as the addition of greenspace.28 Specific actions from the public health sector to address these issues might include the following: S Supporting research to determine the impact that changes in the built environment can have on public health. Just as engineers use data that have been collected over time in other places to determine the diameter of sewer pipe needed to serve a section of a ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ PUBLIC HEALTH/LAND-USE MONOGRAPH S 15 . part of which served as a dumping ground in the 1950s. OH Military Dump River Valley High School and Middle School stand on the former site of the US Army’s Marion Engineering Depot. no one may exit back doors of the middle school or access several playing fields. (2) cleaning up and protecting the environment. public health professionals need to appreciate that the built environment influences public health as much as vaccines or water quality. They are: (1) integrating physical activity into our daily lives. Similarly. Engineers.○ School Case Study Marion. but students remain on the contaminated site until completion. community members formed a group in response to alarming rates of leukemia and rare cancers among former students. Recently a bond issue passed to fund a new school. (3) recog-nizing the contributions of mental health to overall health and well-being. Architects.

and the planners have their say in land-use decisions. land-use decisions were made to separate people from land-uses and industrial processes that posed a threat to their health or safety. It is time for the planning community to remember its roots in public health protection — to remember that in the beginning many. The influence of last century’s community designers on our communities and on the behavior choices that we make everyday was seriously underestimated. the planners and urban designers might take the following actions: S Balancing the potential public health consequences of their choices with other considerations. the school board. controlled growth. It is also critical that when they find that no data or analyses exist to answer the questions that they raise. It is their role to ask the questions such as “Why aren’t there any sidewalks in a new subdivision?” or “What is the air quality impact that is expected from a widening of the local highway?” and to press for evidence to substantiate any claims upon which any new growth and development are based. Just as the developers. S Working with planners and other land-use professionals to provide them with the strong public health arguments they need to support “smart-growth” designs and initiatives. S Participating in local planning processes. local planning and problem-solving workshops where local leaders and decision-makers develop consensus vision of the desired future of their community). The public health and medical community must play an active role in the land-use and development decisions made in their community. if not impossible. Just as there is an expanded role for health care workers and public health professionals in making land-use planning decisions. so too should physicians and public health officials have the opportunity to provide input. and urban planning workshops known as charrettes (intense. “Smart growth” doesn’t mean “no growth. so too is there an expanded role for urban designers and planners to begin to view themselves as a previously untapped force for public health. The obesity epidemic in the United States was never imagined by those who made it difficult. if not most. to walk to the grocery store and to school and who also made it far easier to drive to the shopping mall or the movie theater across town then to walk to 16 S PUBLIC HEALTH/LAND-USE MONOGRAPH ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ . shop or go to school can have a dramatic impact on their health and quality of life. S Changing existing zoning codes to encourage multiuse land-development patterns that make it possible to work. they push researchers and policy makers to collect the information they need and conduct the research to ensure that all of the impacts of various land-use decisions are known before irrevocable actions are community-based.” but it does mean planned. Reviving the concept that the end result of urban design should be improved quality-of-life and that where people live as it relates to where they work. so too should public health officials use data on pedestrian injury patterns to create new urban design techniques. It is their role to make policy makers and planners aware of the health impacts of the decisions they make. To reclaim their role as public health protectors. zoning hearings. shop. the neighbors. and go to school within walking distance of people’s homes. such as comprehensive planning meetings. The health impacts of land-use decisions need to receive at least as much consideration in development decision-making processes as economic impacts. S Designing communities around people rather than around automobiles.

fact that the more each member of society is able to participate and contribute. urban design.] And all of this could be possible if appropriate design choices are made which. reduces violence. and planning have much in common. The mental and physical health benefits of community parks and other green spaces have been demonstrated. ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ PUBLIC HEALTH/LAND-USE MONOGRAPH S 17 Photo: Hugh Morris ○ ○ ○ ○ ○ ○ ○ ○ ○ . S Changing existing building codes to encourage building and site design that is accessible to people who have various degrees of mobility. Public health professionals and those in architecture. To meet these challenges. The challenge now is for each profession to learn from each other how best to address the needs of the communities they serve. S Encouraging greenspace development that promotes community. to create a common language. The question that remains is whether communities want to spend money up front to create an environment that prevents violence and increases psychological well-being or whether they want to spend money after the fact to address the violence and stress which results from communities without parks and communal areas. [Not only would those who were previously hampered by the inaccessibility feel better. the better off society is. in most cases. but they also need less help to participate in society and be more able to contribute to their communities. and improves mental health. would not cost appreciably more or negatively affect others. if largely unrealized. we need a broader view of those factors influencing public health and a much better understanding of the interdisciplinary nature of the problem.such neighborhood establishments. It is a clear. We need a collaborative and concerted effort to influence both public health policy and other public policy on these issues in order for positive changes to take place that will improve the health and quality of life for all Americans. to determine what answers each has that the other needs. and to initiate the opportunities to use it.

Institute of Medicine (US). 13. 6. 110). Department of Health and Human Services (US).who.S.html [ report99/index. Urban roadway congestion annual report 1998. 18. Health Psych 2000. Asthma and the environment: A strategy to protect children (2000) [Online]. Available: http://www. Washington: US 11.html [2001. Nestle M. Environmental Protection Agency (US). (1999) The Sierra Club rates the states [Online]. [Online]. National Council for Science and the Environment. Air quality and motor vehicles: An analysis of current and proposed emission standards [Online]. Available: http://ntl. 272 U. Washington: National Academy of Sciences. Bureau of Transportation Statistics. Massey JT. 1985-1994.S. August 6].gov/DOCS/473.115(1):12-24. August 6]. Department of Health and Human Services (US). et al. Jacobson MF. 15. November 2000. Physical Activity and Public Health: A Recommendation From the Centers for Disease Control and Prevention and the American College of Sports Medicine. World Health Organization. Adverse health effects associated with ozone in the eastern United August 6].47(No. Table 1-54 [Online] Available: http:// 199.References (No date). Parsons VL. (2000) Danger in the air: Smog days in 1999 [Online].htm [ 2001. Hyattsville: Department of Health and Human Services (US). Available: http://www. series 2. Bureau of Transportation Statistics. JAMA 2001. Mor Mortal Wkly Rep 1999:48(7):143-6. 16.pdf [2001.html [2001. August 6]. 7. Available: http://www. p. p. Air and Radiation Office. Available: http://www. Ambler Realty Co. Village of Euclid v. middle-aged and older-aged women.79.asp [2001. [Online]. http://www. EPA. Public Interest Research Group Education Fund.bts. Public Health Rep 2000. 1996. 1960–1995. August 6]. Design and estimation for the National Health Interview Survey. August 6]. Texas Transportation Institute (1999). European Region. Pope. 23. 1960-1990.pirg. (1999) The national transportation statistics report 1999. (No date) Journey-to-work trends in the United States and its major metropolitan areas. MS.sierraclub. Mor Mortal Wkly Rep CDC Surveill Summ 1998. Environmental Protection Agency (US). Tadros W. Washington: (1999). 5. London [Online]. Moore TF.285:897-905. August 6]. 19. 18 S PUBLIC HEALTH/LAND-USE MONOGRAPH . National air quality and trends report. (1999) Congressional Research Service Report for Congress.. Volume 1. 365 (1926) (USSC+). Washington: DHHS.html [2001. August 6]. Available: http://www. Office of Air and Radiation.html [2001. 1988. Personal and environmental factors associated with physical inactivity among different racial-ethnic groups of U.SS-1):1-28. Friedman. Washington: U. Impact of changes in transportation and commuting behaviors during the 1996 summer Olympic games in Atlanta on air quality and childhood asthma.html [2001. King AC. [1999. 9. C.epa. EPA420-F-99-040.bts. November]. Healthy people 2010.273(5):402-7. August 6].S. (PHS)89-1384.cnie.who. Definition of health [Online].int/aboutwho/en/ definition. Department of Transportation (US). 2. Neighborhood safety and the prevalence of physical inactivity –selected states. Pate RR. JAMA 1995. (1999) Third ministerial conference on environment and health.8-3. 7.77/ntda/nts/NTS99/data/Chapter1/1-54. National Center for Health Statistics. 20. 10. Office of Mobile Sources. Halting the obesity epidemic: A public health policy approach. et al. The President’s Task Force on Environmental Health Risks and Safety Risks to Children. Washington: (1996). 14. 21. World Health Organization. 1989. Emission facts. ABT Associates. Available: http://www. 4. 8. Physical activity and health: A report of the surgeon December] 12. Surveillance for asthma–United States.179. et al. Clean Air Network and U. Department of Transportation (US). The future of public health. EPA 454/R-98-016 [1997. (Vital and health statistics. 22. Solving sprawl. Centers for Disease Control and Prevention.19(4):354-64. no. Centers for Disease Control and Prevention.S. 3.

Heat-related illness during extreme weather emergencies.urbanforestrysouth. Do trees strengthen urban PUBLIC HEALTH/LAND-USE MONOGRAPH S 19 . Luvall J (No date) Air pollution prevention through urban heat island mitigation: An update on the urban heat island pilot project [Online].. Available: [2001. Curriero FC. Markham JP. Current and future public health challenges. 29. State of Pennsylvania.htm [2001. 33. Corless J. 1000 Friends of Washington. Caught in the crosswalk: Pedestrian safety in California [Online]. Brownfields Economic Redevelopment Initiative Quick Reference Fact Sheet. Available: http://www. August 6]. 40 Gorsevski V. Taha H.htm [2001. September 30].us/2001/ redefining_progress.transact. August 6]. et [2001 August 6]. Am J Public Health 2001. Rose JB. Wait for the bus [Online]. Int J Aging Hum Dev1998. August 6]. 36. Available: http://www. 46.1514. Mean streets 2000: A transportation and quality of life campaign report [Online].asp [2001. Also available at http://www. Blum LN. reduce domestic violence? In 37.colorado. August 6].nasa. Forestry Report RB-FR 56. Environmental and architectural barriers: How accessible is the urban environment? (1996) [Online]. Prevalence of overweight among children and adolescents: United States. 45. January 1996 [Online].edu/org/sun/housing/cd_v2/Bookarticles/Ch1.S. GA. Adaptive Environments Center. 39. Available: http://www.html [2001. Ohland G. The Sierra Club (No date).adaptenv. Sullivan WC.msfc. Foote KE (1996). Gilderbloom JI. Southern ca/caught99/caught.21stcentury.sierraclub. 32. Sprawl fact sheet [Online]. Available: http://www.279(19).) (No date). Poisoned schools: invisible Available: http:// www.htm [2000. Departments of Community Affairs and Department of Environmental Protection. Alternatives for future urban growth in California’s Central Valley: The bottom line for agriculture and taxpayers [Online]. 28.pdf [2001. Centers for Disease Control and Prevention. August 6]. EPA 500-F-00-241 [Online] Available: http://www. Child Proofing Our Communities: Poisoned School Campaign. 34.24. Forest Service. Quattrochi D.284(13):1697. JAMA 2000. Office Solid Waste and Emergency Response.cdc. Crum S. Redefining progress: recommendations from the 21st century environment commission to Governor Tom Ridge [Online]. JAMA 1998. 27. The association between extreme precipitation and waterborne disease outbreaks in the United States. Prevalence of overweight and obesity among adults: United States. 31. August 6].louisville.1000friends. Available: [2001. (1999) Onsite sewage treatment and disposal in Florida: Draft background paper for the Governor’s study of onsite sewage treatment and disposal systems [Online].epa. August 6]. August 6]. Available: http://www.htm [2001. Colditz. 46(1). BMJ 1995. Available: http:// www.farmlandinfo.htm [2001. Lele S. Available: http://www. August 6].gov/swerosps/bf/ html-doc/econinit. Florida Department of Health. October].htm [2001. Med Sci Sports Exerc 25. [Online] Available: http://www. Fleming. 21st Century Environment Commission (No date). American Farmland Trust (No date).state. Effect of environmental factors on risk of injury of child pedestrians by motor vehicles: A case-control study. 30.91(8):1194-9.htm [2001. Centers for Disease Control and Prevention. August 6]. Available: http://www. August 6].cdc. 1999 [Online]. 38. Department of Agriculture. Sprawl (No date) [Online]. Available: August 6].gov/ swerosps/bf/glossary. Roberts August 6].htm [2001. 43.310(6972):91-4. Available: http://www. 1999 [Online].epa.asp [2001. 35. August 6]. visible actions (2001) [Online]. 26. Kouri C.html [2001. 44. 41.scccl. August 6]. Available: http://www. Patz JA. Adaptive Environments & Universal Design (No date) [Online].ghcc. United States Environmental Protection Agency. [2001. USEPA Office of Solid Waste and Emergency Response Glossary of Terms. Kuo FE. (No date). et Koplan JP.htm#brow [1997. 42. Economic costs of obesity and inactivity. Surface Transportation Policy Project (2000).org/pubs/Tech_bulletin/tb4. Housing quality among the elderly: A decade of changes.

org .. NW • Suite 225 Washington.Sprawl Watch Clearinghouse 1400 16th St. DC 20036 202-332-7000 www.sprawlwatch.

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